Traumatic fistula between internal iliac artery and external iliac vein

Traumatic iliac arteriovenous fistulas (AVFs) are extremely rare, with only two cases reported in literature involving the internal iliac artery and the external iliac vein. We report the case of a 23-year-old man who sustained a gunshot injury to the left lower quadrant of his abdomen and subsequently developed unilateral leg edema of "elephantiasic proportions." Intra-arterial digital subtraction angiography six years later was essential for diagnosis and comprehension of the pathomechanism. The angiographic examination showed an internal iliac false aneurysm, as well as a high-flow arteriovenous communication between the left internal iliac artery and external iliac vein complicated by thrombotic occlusion of the left common iliac vein. The initial vascular injury and the surgical management of simple ligation were thought to be responsible for the iliac AVF and the subsequent thrombosis of the common iliac vein. On the one hand, the thrombotic occlusion of proximal vein led to a sharp increase of mean pressure in the proximal and distal arteries and in the distal vein, resulting in chronic venous insufficiency with incompetent varicose veins. On the other hand, the restriction of venous outflow produced extreme peripheral edema and large superficial veins serving as collaterals to bypass the fistula. Vascular surgery could repair the lesion by closing and bypassing the AVF.     

Iatrogenic venous air embolism caused by CT injector--from a risk management point of view

An iatrogenic venous air embolism caused by computed tomography (CT) injector occurred in a 74-year-old man undergoing abdominal-pelvic CT for evaluation of an abdominal aortic aneurysm (AAA). During the initial inspection scan of the thoracic part, a large amount of air was detected in the right ventricle, but no contrast medium was noted in the aorta. Surface oxygen was given immediately, and the patient was placed in the left lateral decubitus position on the CT bed. During that time he had no symptoms except coughing. CT revealed no air in the brain or pulmonary vein, and he was returned to his room 55 minutes after the incident. There were no complications during a six-month follow-up period. The importance of daily risk management and immediate proper after care to prevent such accidents was reconfirmed.     

动脉晚期CTA融合图像在肾动静脉系统评估中的价值

目的探讨动脉晚期CTA融合图像在肾动静脉系统评估中的价值。方法26例超声提示肾占位的病人及5例活体供肾者,采用德国Siemens Somatom Sensation 16层螺旋CT机,进行了平扫及动脉早期、动脉晚期及实质期3期增强扫描。数据被传到GE ADW 4.2 Workstation进行3D重建,采用Volume viwer plus voxtool 6.3.19软件包。由2位放射科主任医师对肾动静脉系统显示情况进行评估,意见相左时,通过讨论达成共识。结果动脉晚期CTA融合图像对副肾动脉和肾动脉提前分支的显示率与动脉早期相同。左右肾副肾动脉的CTA显示率分别为32.3%和6.5%。左右肾动脉提前分支的显示率分别为12.9%和9.7%。对环主动脉左肾静脉、腹主动脉后左肾静脉及多条右肾静脉,动脉晚期CTA融合图像与实质期的显示率之间亦无差异,分别为16.1%、3.2%及32.3%。动脉晚期CTA融合图像对左肾上腺静脉、左性腺静脉及左腰静脉的显示率为83.9%、87.1%、61.3%,和实质期相比(分别为87.1%、93.5%、64.5%),2组之间无统计学差异(P>0.05)。动脉晚期CTA融合图像质量优于实质期。结论动脉晚期CTA融合图像能够同时且清楚地显示肾动静脉系统,减少了受检者的放射线剂量、节约了检查时间。     

Delayed traumatic intracerebral hemorrhage associated with dolichoectasia of the middle cerebral artery

A 74-year-old man tripped while walking. He had not been administered antiplatelet or anticoagulation therapy. At presentation, the patient was well-oriented, with a blood pressure of 130/91 mmHg, while present with tetraplegia and numbness in the upper extremities. Blood work revealed normal findings, while magnetic resonance imaging of the cervical spine revealed severe cord compression at the C3/4 and C4/5 levels. Cranial computed tomography (CT) showed elongated masses in the Sylvian fissures without intracranial hemorrhage. CT taken 2 days later revealed an intraparenchymal hemorrhage located mainly in the right putaminal region, while the patient showed no signs of neurological deterioration. Three-dimensional CT angiography (3D CTA) demonstrated marked ectasia and elongation in the right internal carotid, bilateral middle cerebral, and left anterior cerebral arteries. The patient was conservatively managed. Repeat 3D CTA performed 3 months later showed no de novo abnormalities in the ectatic cerebral arteries. It is assumed that the delayed traumatic intracerebral hemorrhage was caused by disruption of the perforating vessels arising from the ipsilateral dolichoectatic middle cerebral artery. Periodical surveillance neuroimaging is recommended for patients with head trauma who are simultaneously diagnosed with incidental dolichoectasia, especially when complicated with cervical cord injury.     

Preoperative assessment of vascular anatomy around the stomach by 3D imaging using MDCT before laparoscopy-assisted gastrectomy

OBJECTIVE: Our aim was to evaluate the efficacy of 3D imaging using MDCT in the preoperative assessment of the vascular anatomy around the stomach before laparoscopy-assisted gastrectomy. SUBJECTS AND METHODS. Thirty-six consecutive patients scheduled for laparoscopy-assisted distal gastrectomy were evaluated on MDCT. CT was performed at the arterial phase after a bolus IV injection of contrast material. Three-dimensional CT angiography (3D CTA) of the arterial and venous systems was reconstructed separately using a volume-rendering algorithm, and the images were fused. Three-dimensional CTA for the left gastric, right gastric, and replaced left hepatic arteries and the left gastric coronary vein was evaluated prospectively by three reviewers, and then a surgical correlation was made. RESULTS: In all 36 cases, the left gastric artery was correctly identified on 3D CTA. In 35 of 36 cases, the right gastric artery was correctly identified, whereas in one case, the right gastric artery could not be visualized on 3D CTA because of its small size. In 35 of 36 cases (i.e., one case with agenesis of the left gastric coronary vein was excluded), the left gastric coronary vein was correctly identified. In six cases, the replaced left hepatic artery was correctly identified on 3D CTA. All 36 cases underwent successful laparoscopy-assisted distal gastrectomy on the basis of the 3D CTA. Both the sensitivity and positive predictive values of 3D CTA revealed 100% correct determination of the left gastric artery, replaced left hepatic artery, and left gastric coronary vein. The sensitivity and positive predictive values for the right gastric artery were 97% and 100%, respectively. CONCLUSION: Three-dimensional CTA using MDCT clearly revealed individual vascular anatomies around the stomach and could play an important role in safely facilitating the laparoscopy-assisted gastrectomy procedure.     

CT血管成像对髂静脉受压综合征及继发血栓形成的诊断价值

目的 探讨CTA对髂静脉受压综合征(IVCS)及继发血栓形成的临床应用价值.方法 回顾性分析80例正常对照组和经DSA证实的31例IVCS患者的CTA资料,测量2组受压髂静脉的前后内径,计算受压程度,并采用t检验和Wilcoxon秩和检验进行比较.以DSA为诊断标准,统计IVCS的CTA诊断符合率.结果 对照组受压左髂总静脉前后内径女性组为(7.0±2.5)mm,小于男性组(8.1±2.5)mm;t值=2.42,P＜0.05);左髂总静脉受压程度男性组(0～61.36%,中位数为26.82%)与女性组(0～65.41%,中位数为28.75%)差异无统计学意义(Z=-0.59,P＞0.05).对照组受压左髂总静脉前后内径为(7.6±2.0)mm,受压程度为0～65.41%,中位数为27.65%;IVCS组受压髂静脉前后径为(2.7±1.1)mm,髂静脉的受压程度为55.18%～100.00%,中位数为76.12%,受压髂静脉前后内径小于对照组(t=12.78,P＜0.05),受压程度大于对照组(Z=-8.18,P＜0.05).31例IVCS中,左髂总静脉受压28例,右侧髂总静脉受压2例,另1例左右髂总静脉分别受到左右髂总动脉压迫.15例继发髂股静脉血栓形成,CTA诊断结果均与DSA结果相符合.结论 CTA能准确测量受压髂静脉前后内径并判断受压程度,CTA还能清楚显示IVCS的继发髂股静脉血栓形成,是诊断IVCS的有效方法.     

Transcatheter arterial embolization using poly-L-lactic acid microspheres

PURPOSE: To assess the use of poly-L-lactic acid (PLLA) microspheres as an embolic material in transcatheter arterial embolization (TAE). MATERIALS AND METHODS: Between December 1993 and August 1995, eight patients [dural arteriovenous fistula (AVF) (n = 1), acute hemoptysis (n = 7)] underwent nine TAE procedures using PLLA microspheres. The patients were four men and four women, aged 38-82 years (mean, 62.4 years). All procedures were performed through a 3-F microcatheter inserted coaxially into a 5-F angiographic catheter via the right femoral artery. RESULTS: TAE using PLLA was technically successful in all patients. Flow stasis of the targeted arteries was obtained immediately after TAE. Clinical symptoms improved immediately after the procedure, and there was no recurrence during the follow-up period. Procedure-associated complications were not observed, except for slight fever up to 38 degrees C for three days that was managed conservatively. CONCLUSION: PLLA appeared to be a suitable embolic material for use in TAE when permanent occlusion is required. As PLLA particles can be prepared in any size, they are suitable for distal occlusion of arteries, thus avoiding proximal occlusion where the recruitment of collaterals is problematic.     

DSA引导下泡沫硬化术与大隐静脉高位结扎联合血管腔内激光术治疗下肢静脉曲张的疗效观察

目的探讨DSA引导下聚多卡醇泡沫硬化术与大隐静脉高位结扎术联合血管腔内激光术治疗下肢静脉曲张的临床疗效。 方法选取60例下肢静脉曲张患者（共66条腿）,随机分为DSA引导下聚多卡醇泡沫硬化术组（A组,30例共33条腿）及大隐静脉高位结扎术联合血管腔内激光术组（B组,30例共33条腿）。分别对两组患者手术时间、住院费用、术后并发症、治疗效果进行对比评价。 结果A组患者手术时间、住院费用明显低于B组（均P<0.01）;A组患者术后皮下瘀血、感觉麻木、皮下脂肪液化感染、皮肤灼伤的发生率均显著低于B组（均P<0.01）;两组患者静脉炎的发生率差异无统计学意义（P>0.05）;两组患者出院时及术后3个月、6个月、1年治疗效果比较差异均无统计学意义（均P>0.05）。 结论DSA引导下聚多卡醇泡沫硬化剂治疗下肢静脉曲张是一项创伤小、并发症少、安全、有效的治疗方法。     

Transcatheter Embolization of a Renal Arteriovenous Fistula Complicated by an Aneurysm of the Feeding Renal Artery

Renal arteriovenous fistula (AVF) is rare. Renal AVF complicated by aneurysm of the feeding artery presents a technical challenge for endovascular treatment. We report a case managed by covered stenting of the renal artery aneurysm, coil embolization of the fistula, and bare stenting of the aorta.     

Left ventricular true and false aneurysms identified by cardiovascular magnetic resonance

Left ventricular aneurysms are uncommon complications of myocardial infarction. However, it is important to identify them because they are associated with increased morbidity and mortality. True aneurysms tend to be managed conservatively whereas false aneurysms, because of the risk of rupture, are usually treated with urgent surgery. Distinguishing these two subtypes is therefore critical and cardiovascular magnetic resonance (MR) is being used more frequently to characterise the type of aneurysm as well as to provide clear three-dimensional images of aneurysm morphology. We present a very rare case of a true and a false aneurysm of the left ventricle in the same patient. MR enabled accurate delineation of both aneurysms and the late gadolinium-enhancement images provided evidence confirming both true and false aneurysms to be present.     

Diverticula of Kommerell and Aberrant Subclavian Arteries Complicated by Aneurysms

This is a retrospective evaluation of the incidence of aberrant subclavian arteries (ASAs) and diverticula of Kommerell, as well as the occurrence and significance of associated aneurysms. Thoracic aortograms obtained during a 12.5-year period were reviewed, seeking the presence of aberrant right and left subclavian arteries (ARSAs/ALSAs), diverticula of Kommerell, and the incidence of associated aortic aneurysms. Several cases were evaluated with computed tomography concomitantly. Results were correlated with a literature review. Twenty-two ASAs were identified. Nineteen were on the right (ARSAs) and three were on the left (ALSAs). A diverticulum of Kommerell (DOK) was also present on the right in seven and on the left in three. Five of these patients had complicating aneurysms. Four of these were associated with ARSAs and their diverticula. Two were atherosclerotic; one was a limited dissection and one of uncertain etiology was ruptured. One additional aneurysm (atherosclerotic) involved an ALSA/DOK. The patient with the ruptured aneurysm died in surgery; three were managed conservatively because of concomitant disease; and one is being followed because of the small size (2.5 cm) of the aneurysm. ARSAs are relatively uncommon and ALSAs are rare. Both ARSA and ALSA are frequently associated with a DOK. Aneurysms rarely involve ASAs (with or without a DOK), but they are associated with a high mortality rate if they are not discovered before rupture. Early diagnosis plus surgical and/or endovascular management can be lifesaving.     

不同部位注射对比剂对颈动脉血管CT造影图像质量的影响

 目的 探讨通过左、右肘注射对比剂对颈动脉CT造影(CTA)成像图像质量的影响。方法 回顾性分析2019-09至2021-06在武警北京总队医院医学影像科行头颈部CTA检查的100例患者,其中50例经右臂肘正中静脉注射对比剂的为右臂组,50例经左臂肘正中静脉注射对比剂的为左臂组;对比两组患者两侧颈动脉CT值及静脉显影优良率。结果 右臂组及左臂组的左颈总动脉CT值分别为(335.25±20.67)Hu、(315.78±20.67)Hu,右颈总动脉CT值分别为(330.28±18.45)Hu、(313.56±19.45)Hu,差异无统计学意义(P＞0.05);右臂组静脉显影优良率为86.00%,高于左臂组的63.00%,差异有统计学意义(P＜0.05)。结论 颈动脉CT血管造影采用右臂静脉注射对比剂,可减少上腔静脉、头臂静脉、锁骨下静脉伪影及对比剂反流。     

Endovascular treatment of arteriovenous fistula caused by ruptured iliac aneurysm and type II endoleak

Arteriovenous fistulas (AVFs) caused by an isolated iliac aneurysm rupture and postoperative type II endoleak are rare and life threatening. We report here a case of AVF caused by a ruptured iliac aneurysm and postoperative type II endoleak. The patient was successfully treated by implanting a covered stent to treat the ruptured iliac aneurysm. However, type II endoleak with AVF persisted after the operation and was treated with transiliac vein embolization. The patient recovered uneventfully during the 2-month follow-up period.     

Pelvic Vein Embolisation in the Management of Varicose Veins

Pelvic vein incompetence is common in patients with atypical varicose veins, contributing to their recurrence after surgery. Therefore, refluxing pelvic veins should be identified and treated. We present our experience with pelvic vein embolisation in patients presenting with varicose veins. Patients presenting with varicose veins with a duplex-proven contribution from perivulval veins undergo transvaginal duplex sonography (TVUS) to identify refluxing pelvic veins. Those with positive scans undergo embolisation before surgical treatment of their lower limb varicose veins. A total of 218 women (mean age of 46.3 years) were treated. Parity was documented in the first 60 patients, of whom 47 (78.3%) were multiparous, 11 (18.3%) had had one previous pregnancy, and 2 (3.3%) were nulliparous. The left ovarian vein was embolised in 78%, the right internal iliac in 64.7%, the left internal iliac in 56.4%, and the right ovarian vein in 42.2% of patients. At follow-up TVUS, mild reflux only was seen in 16, marked persistent reflux in 6, and new reflux in 3 patients. These 9 women underwent successful repeat embolisation. Two patients experienced pulmonary embolisation of the coils, of whom 1 was asymptomatic and 1 was successfully retrieved; 1 patient had a misplaced coil protruding into the common femoral vein; and 1 patient had perineal thrombophlebitis. The results of our study showed that pelvic venous embolisation by way of a transjugular approach is a safe and effective technique in the treatment of pelvic vein reflux.     

Transvenous Embolization of a Spontaneous Femoral AVF 5 Years After an Incomplete Treatment with Arterial Stent-Grafts

A 66-year-old man with complex left femoral arterio-venous fistula (AVF) was first diagnosed after a deep venous thrombosis incident approximately 5 years ago. Partial treatment was performed by means of endografts along the superficial femoral artery, which remained patent for 5 years. The patient had been doing well until a couple of months ago when he developed severe venous stasis and ulcers of the left cruris, due to a high-flow nonhealing complex AVF with additional iliac vein occlusion. Therefore; the definitive treatment was performed by a unique endovascular technique combined with surgical venous bypass (femoro-femoral crossover saphenous bypass, the Palma operation). A novel percutaneous transvenous technique for occlusion of a complex high-flow AVF is reported with a review of the literature. The case is unique with spontaneous AVF, transvenous embolization with detachable coils and ONYX, and the hybrid treatment technique as well as the long-term patency of superficial femoral artery stent-grafts.     

64层3D-CTA与3D-DSA对颅内动脉瘤评价的对比研究

目的 对比评价64层螺旋CT三维血管造影(3D-CTA)与三维数字减影血管造影(3D-DSA)对颅内动脉瘤的诊断价值.方法 28例临床怀疑颅内动脉瘤的患者均行64层螺旋CT血管造影和DSA,CT三维后处理主要包括容积重建(VR)及最大密度投影(MIP).常规二维DSA检查后,对可疑病变血管行旋转DSA检查,应用三维工作软件行3D后处理,比较3D-CTA与3D-DSA对动脉瘤显示的价值.结果 28例病例中22例CTA和DSA均显示动脉瘤并经手术或栓塞证实,其中1例CTA和DSA显示单个动脉瘤,手术证实为2个动脉瘤,1例CTA显示假阳性.3D-CTA与3D-DSA均能清楚显示动脉瘤形状、瘤径指向、瘤体直径、瘤颈、载瘤动脉、瘤体穿动脉情况,两者无明显差异.结论 64层3D-CTA在颅内动脉瘤诊断及细节显示上与3D-DSA无明显差异,一定程度上应能替代血管造影,指导临床治疗.     

Imaging and management of complications of open surgical repair of abdominal aortic aneurysms

Open repair is still considered the reference standard for long-term repair of abdominal aortic aneurysms (AAA). In contrast to endovascular aneurysm repair (EVAR), patients with open surgical repair of AAA are not routinely followed up with imaging. Although complications following EVAR are widely recognized and routinely identified on follow-up imaging, complications also do occur following open surgical repair. With frequent use of multi-slice computed tomography (CT) angiography (CTA) in vascular patients, there is now improved recognition of the potential complications following open surgical repair. Many of these complications are increasingly being managed using endovascular techniques. The aim of this review is to illustrate a variety of potential complications that may occur following open surgical repair and to demonstrate their management using both surgical and endovascular techniques.     

Coil Protruding into the Common Femoral Vein Following Pelvic Venous Embolization

Pelvic venous embolization is performed for pelvic congestion syndrome and prior to lower limb varicose vein surgery in females with associated pelvic venous insufficiency. The procedure is analogous to varicocele embolization in males, although refluxing internal iliac vein tributaries may also be embolized. We report a case of inadvertent coil placement in the common femoral vein while embolizing the obturator vein, during pelvic vein embolization for recurrent lower limb varicose veins. There were no clinical consequences and the coil was left in situ. We advise caution when embolizing internal iliac vein tributaries where there is clinically significant communication with veins of the lower limb.     

Preoperative evaluation of perigastric vascular anatomy by 3-dimensional computed tomographic angiography using 16-channel multidetector-row computed tomography for laparoscopic gastrectomy in patients with early gastric cancer

PURPOSE: The purpose of this study was to evaluate the efficacy of 3-dimensional computed tomographic angiography (3D CTA) using 16-channel multidetector-row helical computed tomography (MDCT) in the preoperative visualization of laparoscopic gastrectomy for early gastric cancer. MATERIALS AND METHODS: Twenty consecutive patients with early gastric cancer who underwent computed tomographic (CT) examination using 16-channel MDCT (0.625 mm x 16) before surgery were included in this study. At a rate of 4 mL/s, 2 mL/kg of 300 mg I/mL contrast material was intravenously injected. Timing for arterial phase scanning was determined by using a test bolus injection. Portal phase imaging was performed 70 seconds after the start of bolus injection. By using volume rendering and maximum intensity projection techniques, 3D CT angiograms of perigastric vessels were reconstructed from CT images of 0.625-mm thickness on computer workstations. RESULTS: In all cases, the left gastric artery (LGA) and the right gastric artery were correctly identified on 3D CTA, and the left gastric vein was also depicted on 3D CTA in all cases. In 2 cases, the aberrant left hepatic artery from LGA was correctly identified on 3D CTA. In 1 case, the accessory LGA from the left hepatic artery was correctly identified on 3D CTA. The variations of the veins included the left gastric vein flowing into the portal vein in 10 cases: the splenic vein in 9 and the junction of the portal and splenic veins in 1. CONCLUSIONS: A 3D CTA reconstructed from 16-channel MDCT images clearly revealed perigastric vascular anatomy in all cases, which is important for laparoscopic gastrectomy. Three-dimensional CTA is useful for the preoperative visualization of laparoscopic gastrectomy.     

Arteriolymphatic Fistula: An Unusual Cause of Spontaneous Swelling in the Left Supraclavicular Region

An abnormal fistulous communication between an artery and lymphatic system is a rare occurrence. We report a 38-year-old male presenting with sudden onset, spontaneous, pulsatile swelling in the left supraclavicular region following a recent cardiac catheterisation via right femoral arterial access. On evaluation, he was found to have a femoral arteriolymphatic fistula. He was managed conservatively with ultrasound-guided compression with complete resolution of symptoms at follow-up. This case describes a hitherto unknown complication of percutaneous vascular cannulation presenting in an unusual manner, diagnosed with Doppler Ultrasonography and CT angiography and managed effectively with a non-invasive therapeutic image-guided manoeuvre.